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2025 CPT code 11970

Replacement of a tissue expander with a permanent implant.

Follow current CPT guidelines for surgical procedures and appropriate documentation.Modifiers may be necessary depending on the circumstances of the procedure.

Modifiers 50 (bilateral procedure), 51 (multiple procedures), 52 (reduced services), 59 (distinct procedural service), and others may apply depending on the specifics of the case.

Medical necessity is established when the tissue expander has reached the desired volume and a permanent implant is needed to complete the breast reconstruction.This may be due to expander deflation or the patient's desire for a permanent solution.

The surgeon's responsibilities include prepping and anesthetizing the patient, making an incision, removing the tissue expander, inserting the permanent implant, securing the implant (if necessary), and closing the incision.

IMPORTANT:For removal of a tissue expander without implant placement, see 11971. For insertion of a tissue expander (other than breast), see 11960.

In simple words: The doctor replaces a temporary device (tissue expander) that stretched the skin with a permanent breast implant.

This procedure involves the surgical removal of a previously placed tissue expander and its replacement with a permanent implant (artificial implant or tissue graft).The surgeon makes an incision at the expander site, removes the expander, inserts the permanent implant, and secures it using screws or wires if necessary. The incision is then closed with sutures.

Example 1: A patient undergoes a mastectomy followed by tissue expander placement. After several weeks of expansion, the expander is replaced with a permanent silicone implant during an exchange surgery., A patient with breast cancer undergoes a mastectomy and immediate tissue expander placement.Following expansion, the expander is replaced with a permanent implant during a second surgical procedure.Additional fat grafting is performed to improve the cosmetic result., A patient who previously underwent breast reconstruction with a tissue expander experiences expander deflation.The deflated expander is surgically removed, and a new permanent implant is placed.

Preoperative and postoperative photos, operative report detailing the expander removal and implant placement, type of implant used, any additional procedures performed (e.g., fat grafting), and pathology reports if applicable.

** The procedure may be performed bilaterally.Careful attention should be paid to accurate documentation of the implant type and any additional procedures performed during the same surgical session.

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